DEFINING, DIALOGING, AND DIALYSING THE ELDERLY
David C. Lowance, M.D.
LifeLink of Georgia. Atlanta, Georgia, USA
In recent years there has been an attempt to categorize patients by chronologic age or disease process in order to better define outcomes and to identify factors that might influence outcomes of interventional therapies. Although these arbitrary separations are useful for studies, they all share the inherent risk of inappropriately influencing a caregiver’s thoughts regarding the suitability of a given patient for a specific treatment whether it be dialysis, cardiac surgery, or other life saving and life extending, expensive technologic interventions.
An appropriate question to ask is, "Should specific ages or disease designations be utilized in defining who should be offered an interventional therapy?" If one asks this question, one should also be willing to discuss who should be the person or what should be the deciding process by which the appropriateness of offering or not offering the therapy is made. What are the deciding criteria? If one asks these questions, it soon becomes apparent to the inquirer that uniformity in response is almost impossible to obtain. Defining criteria becomes more complex as modernized, developed world technologies are introduced to less developed, less affluent societies.
To most families, the loss of a loved one is equally painful whether rich or poor, old or young, diseased or not diseased. A loss is still a loss.
How then should one define "elderly" population and should these persons be approached differently than the other "non-elderly" population. Clearly, there is no way to arrive at a uniform definition. Likewise, there is no way to define "a limiting co-morbid condition" that would preclude the offering of dialysis to any given patient. There can only be discussions of generalities and suggestions of guidelines to be utilized when encountering patients whom the caregiver is uncertain will benefit from a specific intervention. For patients with chronic end state renal disease, three sets of guidelines have been published, all from the United States, a country with enough affluence presently to enjoy the luxury of being able to offer the technology of dialysis to all persons with kidney failure (1,2,3). These guidelines are personal, consensual, and evidenced based. However, they are from one society and they might be different if they had originated in a different society. Likewise, I suspect the term "elderly" would be defined differently in a society where the average life expectancy were 40 years compared to a society where the life expectancy might be 70 years.
The difficulty in defining what the term "elderly" actually means should serve as a wake up call to all persons providing healthcare. The term "elderly" is a relative term, open to numerous interpretations. If this be true, patients would probably be better served by not being placed in such an arbitrary category. It is probably more suitable to view each patient encountered as a viable human who may or may no benefit from a therapeutic intervention. Assigning arbitrary age requirements or disease elimination categories as criteria for eligibility to receive a medical intervention is a dangerous road to travel.
How then should we discuss these issues with this hard to define population of patients? We should practice the principle of informed consent which means full disclosure to the patient of the risks, potential benefits, and cost of the intervention. Frequently it is clear to the care-giving team that certain interventions may carry more risks and burdens than potential benefits. Frequently, the patients do not understand this discrepancy between the desired outcomes they wish for themselves and the likelihood of their being achieved. It behooves the caregivers to understand that patients may require a period of time to understand the complexities of the interventions contemplated. We should restrain our feelings of frustration and enter into earnest educational dialogue with the patients in order to bring them to a level of understanding that allows them to make appropriate decisions for themselves.
In the United States and many industrialized countries the element of cost has been removed from the decision making process of the patients since dialysis is uniformly financed by the government. This situation may not necessarily be right and may change in the future. In societies where dialysis is not financed by others, patients and their families have to consider the financial cost of the intervention in deciding what is best for them and their families. Whenever possible, patients or their surrogates should be the persons who decide whether the benefits outweigh the burdens of the therapy to justify its initiation or cessation. It is often appropriate to offer a limited trial of dialysis if it is unclear to the patients what the process realistically entails.
How should one technically approach dialysis in a population of patients whose life expectancy is short because of age, the presence of co-morbid conditions, or lack of funding ? To me the answer is simple. Even though the procedure is technical it should be viewed as part of a holistic approach in the care of these patients. If their life expectancy is short, maximizing the longevity of their lives should be balanced against maximizing the quality of their lives. Our native kidneys work twenty- four hours a day, seven days a week with efficiency far in excess of what our machines can achieve.
We will not match what our patients have already lost. Our goals should be to provide for them what they desire for themselves after being fully informed of both our limitations and theirs. Requiring an "elderly" person to receive the same intensity level of treatment as a person with a long life expectancy is analogous to requiring an infant to receive the same dose of medication as an adult. It is treating a number instead of a patient. In both instances, the goal should be to give the appropriate dose of treatment to the appropriate individual. Parameters and guidelines should be discussed, reviewed, and therapy instituted with each individual patient only after he is fully informed. A balance between what is technically feasible to deliver and what is best for the patient should result from an ongoing dialogue between the patient and his care-givers.
We are privileged to be able to offer life extending technologies to appropriate patients. It is our responsibility to offer the interventions appropriately, understanding ourselves that the ability to provide is with the permission of the patients we serve.
1} Lowance, DC: Factors and Guidelines to be considered in Offering Treatment to Patients with End-Stage Renal Disease: A Personal Opinion. AKJ vol. 21, No 6(June): 679-683, 1993.
2) National Kidney Foundation, Inc: 1996 Summary and Recommendations in Initiation or Withdrawal of Dialysis in End-Stage Renal Disease: Guidelines for the Health Care Team. New York, NY. pp iii-iv.
3) Renal Physicians Association and American Society of Nephrology: Shared Decision –Making in the Appropriate Initiation of and Withdrawal from Dialysis. Clinical Practice Guideline Number 2, Washington, DC, February 2000.